Healthcare Provider Details

I. General information

NPI: 1538146378
Provider Name (Legal Business Name): SEQUIM REHABILITATION LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/22/2005
Last Update Date: 02/17/2025
Certification Date: 02/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 S 5TH AVE
SEQUIM WA
98382-3944
US

IV. Provider business mailing address

1000 S 5TH AVE
SEQUIM WA
98382-3944
US

V. Phone/Fax

Practice location:
  • Phone: 360-582-3900
  • Fax: 360-582-3903
Mailing address:
  • Phone: 360-582-3900
  • Fax: 360-582-3903

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number1374
License Number StateWA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier4113742
Identifier TypeMEDICAID
Identifier StateWA
Identifier Issuer

VIII. Authorized Official

Name: MARY E. KOFSTAD
Title or Position: CEO
Credential:
Phone: 971-224-2033